CNS Material Request Form

CNS Material Request Form1 Requester InformationDate of RequestRequester NameRequester Group or AffiliationRequester phone, email2 Material InformationNew Chemical Biological Material Nanomaterial2.1 Material Name:2.2 Material Description:3 Describe Intended Use (attach sheets if required)3.1 CNS Labs/Facilities where Material proposed to be used:3.2 Container type and size:3.3 Proposed date to bring into Laboratory:3.4 Description of proposed use including anticipated quantities:3.5 Proposed date to remove from Laboratory:Requester SignatureTo be completed by CNS / EHS staffMSDS ReceivedDate4 AssessmentApproved Approved with special instruction RejectedReviewed ByDateRequester contacted by: __Email __ Phone ___Fax Contacted by: Date:Instructions on reverseFM006_r1_10_Material Request.doc 03/10/09

FM006 Instructions1. Purpose of this Form:1.1. To ensure that no dangerous or contaminating materials are brought into CNS laboratories withoutprior stipulations on handling and use. This form provides a mechanism for advanced review andapproval of all new chemicals, biological materials, and nanomaterials before they can be brought intoany CNS lab or clean room.2. Scope:2.1. This procedure applies to any liquid or gas chemical, any material to be stored, any substance likelyto contaminate laboratories or equipment, any toxic, hazardous, infectious, or radioactive material.2.2 This procedure applies to any material which may be subjected to grinding, scribing, sawing,polishing, breakage, or any other activity where dust may be generated.2.3 This procedure applies to any person who has been approved to work in any CNS Laboratory at 11Oxford Street Cambridge MA.3. How to fill out the Form:3.1. Complete Material Name: Chemical/material/product name that is on the bottle (i.e. SU8 2000 photoresistseries )3.2 Describe material including known hazards, and list ingredients of known.3.3 List all CNS locations in LISE building where material is to be used (cleanroom, B15A ..)3.2. Container Type & Size: how will material be brought into lab and how stored. For example, 4 literglass bottle, 5 gram syringe, one gallon plastic …3.5. Proposed Date to Bring into Lab: What date do you hope to start using this material?3.6. Proposed Date to Remove from Lab: When do you expect experiments will cease?3.8. Description of Use: Describe how this material will be used, how much of this chemical do you planon using, how the material will be handled.4. Submitting Form4.1. Complete the form and attach a Material Safety Data Sheet and bring to the CNS AdministrativeOffice in LISE, room 3064.2. Users are not allowed to enter CNS labs/facilities with requested chemical until this form is signed byall parties and the User receives an approval email from LISE EHS Officer.5. Responsibilities of CNS Administrator5.1. Administrator will ensure the following: All fields are filled out properly, Form is signed by User, andhardcopy of MSDS (if available) is attached.5.2. CNS Admin will forward the form and MSDS to EH&S6. Responsibilities of LISE EHS Officer6.1 Review Material Request Form and material safety data sheet.6.2 Approve or reject. A chemical may be disapproved based on the following criteria:6.21 CNS may already have a similar chemical on site.6.2.2 The toxicity/reactivity data for the material may be unacceptable. If a material is a carcinogen you willbe asked to provide evidence that you investigated less toxic material. If a less toxic substitute can not befound the use of the chemical will be limited and controlled.6.2.3 Material Safety Data Sheet was provided with the chemical.6.3. Contact requestor to notify of approval or rejection and discuss any special concerns and wastecollection strategies.6.4. Turn around time for approval is between 48 and 72 hours.6.5. Maintain the records in the G56 office of LISE under the Material Safety Data Sheet file cabinet.FM006_r1_10_Material Request.doc 03/10/09